Measuring clinician experience in value-based healthcare initiatives: a 10-item core clinician experience measure (CEM-10).

Objective Clinician's experiences of providing care are identified as a key outcome associated with value-based healthcare (VBHC). In contrast to patient-reported experience measures, measurement tools to capture clinician's experiences in relation to VBHC initiatives have received limited attention to date. Progressing from an initial 18-item clinician experience measure (CEM), we sought to develop and evaluate the reliability of a set of 10 core clinician experience measure items in the CEM-10. Methods A multi-method project was conducted using a consensus workshop with clinicians from a range of NSW Health local health districts to reduce the 18-item CEM to a short form 10-item core clinician experience measure (CEM-10). The CEM-10 was deployed with clinicians providing diabetes care, care for older adults and virtual care across all districts and care settings of New South Wales, Australia. Psychometric analysis was used to determine the internal consistency of the tool and its suitability for diverse clinical contexts. Results Consensus building sessions led to a rationalised 10-item tool, retaining the four domains of psychological safety (two items), quality of care (three items), clinician engagement (three items) and interprofessional collaboration (two items). Data from four clinician cohorts (n = 1029) demonstrated that the CEM-10 four-factor model produced a good fit to the data and high levels of reliability, with factor loadings ranging from 0.77 to 0.92, with Cronbach's alpha (range: 0.79-0.90) and composite reliability (range: 0.80-0.92). Conclusions The CEM-10 provides a core set of common clinician experience measurement items that can be used to compare clinician's experiences of providing care between and within cohorts. The CEM-10 may be supported by additional items relevant to particular initiatives when evaluating VBHC outcomes.

Future research priorities for soft-tissue knee injuries.

Aims: To identify unanswered questions about the prevention, diagnosis, treatment, and rehabilitation and delivery of care of first-time soft-tissue knee injuries (ligament injuries, patella dislocations, meniscal injuries, and articular cartilage) in children (aged 12 years and older) and adults. Methods: The James Lind Alliance (JLA) methodology for Priority Setting Partnerships was followed. An initial survey invited patients and healthcare professionals from the UK to submit any uncertainties regarding soft-tissue knee injury prevention, diagnosis, treatment, and rehabilitation and delivery of care. Over 1,000 questions were received. From these, 74 questions (identifying common concerns) were formulated and checked against the best available evidence. An interim survey was then conducted and 27 questions were taken forward to the final workshop, held in January 2023, where they were discussed, ranked, and scored in multiple rounds of prioritization. This was conducted by healthcare professionals, patients, and carers. Results: The top ten included questions regarding prevention, diagnosis, treatment, and rehabilitation. The number one question was, 'How urgently do soft-tissue knee injuries need to be treated for the best outcome?'. This reflects the concerns of patients, carers, and the wider multidisciplinary team. Conclusion: This validated process has generated ten important priorities for future soft-tissue knee injury research. These have been submitted to the National Institute for Health and Care Research. All 27 questions in the final workshop have been published on the JLA website.

Women's Preferences for Hypofractionated Radiation Therapy for Treatment of Early-Stage Breast Cancer: A Discrete Choice Experiment.

PURPOSE: The primary treatment recommended for early-stage breast cancer is breast conserving surgery followed by external beam radiation therapy of the whole breast. Previously, radiation therapy for early-stage breast cancer was given using more fractions over longer durations. Guidelines support treatments with fewer fractions over a shorter time (hypofractionated radiation therapy). This study aimed to understand women's preferences for different features of treatments for early-stage breast cancer. METHODS AND MATERIALS: A discrete choice experiment with 12 choice tasks was conducted, describing the treatments by extent of surgery, duration of radiation treatment, need to relocate for treatment, local side effects, changes in breast appearance, costs, and difficulty with daily activities during and after treatment. Participants were women with breast cancer and from the general population. Mixed logit analyses were conducted and trade-offs between attributes estimated. RESULTS: Four hundred twenty respondents completed the discrete choice experiment. The relative importance of attributes varied by respondent characteristics; the most influential attribute for younger women was type of surgery (breast conserving surgery). Type of surgery did not influence older women's preferences. Shorter treatment duration, avoiding relocation, fewer local side effects, and less difficulty with daily activities all positively influenced treatment preference. Younger women were willing to accept 32 to 40 days of radiation treatment before a treatment that included mastectomy was potentially acceptable. CONCLUSIONS: Attributes of treatment such as duration, need for relocation, side effects, and effects on normal daily activities during and after treatment significantly influenced women's preference for treatment, including surgery. Our findings have the potential for real impact for patients and services including supporting one-on-one clinical discussions, supporting program and patient resource development, and informing service funding, organization, and delivery.

Evaluating clinician experience in value-based health care: the development and validation of the Clinician Experience Measure (CEM).

BACKGROUND: Clinicians' experiences of providing care constitute an important outcome for evaluating care from a value-based healthcare perspective. Yet no currently available instruments have been designed and validated for assessing clinicians' experiences. This research sought to address this important gap by developing and validating a novel instrument in a public health system in Australia. METHODS: A multi-method project was conducted using co-design with 12 clinician leaders from a range of NSW Health Local Health Districts to develop the Clinician Experience Measure (CEM). Validity and reliability analyses were conducted in two stages, first assessing face and content validity with a pool of 25 clinicians and then using psychometric analysis with data from 433 clinicians, including nurses, doctors and allied health and representing all districts within one jurisdiction in Australia. RESULTS: Data gathered from 25 clinicians via the face and content validity process indicated that the initial 31-items were relevant to the range of staff employed in the NSW state health system, with minor edits made to the survey layout and wording within two items. Psychometric analysis led to a rationalised 18-item final instrument, comprising four domains: psychological safety (4-items); quality of care (5-items); clinician engagement (4-items) and interprofessional collaboration (5-items). The 18-item four-factor model produced a good fit to the data and high levels of reliability, with factor loadings ranging from .62 to .94, with Cronbach's alpha (range: .83 to .96) and composite reliability (range: .85 to .97). CONCLUSIONS: The CEM is an instrument to capture clinicians' experiences of providing care across a health system. The CEM provides a useful tool for healthcare leaders and policy makers to benchmark and assess the impact of value-based care initiatives and direct change efforts.

An 11-year longitudinal analysis of refracture rates and public hospital service utilisation in Australia's most populous state.

This detailed 11-year longitudinal analysis calculated the public health cost of managing refractures in people aged ≥ 50 years in Australia's most populous state. It provides current and projected statewide health system costs associated with managing osteoporosis and provides a foundation to evaluate a novel statewide model of fracture prevention. PURPOSE: The purpose of this longitudinal analysis was to calculate current and projected refracture rates and associated public hospital utilisation and costs in New South Wales (NSW), Australia. These results will be used to inform scaled implementation and evaluation of a statewide Osteoporotic Refracture Prevention (ORP) model of care. METHODS: Linked administrative data (inpatient admissions, outpatient attendances, Emergency Department presentations, deaths, cost) were used to calculate annual refracture rates and refracture-related service utilisation between 2007 and 2018 and healthcare costs between 2008 and 2019. Projections for the next decade were made using 'business-as-usual' modelling. RESULTS: Between 2007 and 2018, 388,743 people aged ≥ 50 years experienced an index fracture and 81,601 had a refracture. Refracture was more common in older people (rising from a cumulative refracture rate at 5 years of 14% in those aged 50-64 years, to 44% in those aged > 90 years), women with a major index fracture (5-year cumulative refracture rate of 26% in females, compared to 19% for males) or minimal trauma index fracture and those with an osteoporosis diagnosis (5-year cumulative refracture rate of 36% and 22%, respectively in those with and without an osteoporosis diagnosis). Refractures increased from 8774 in 2008 to 14,323 in 2018. The annual cost of refracture to NSW Health increased from AU$130 million in 2009 to AU$194 million in 2019. It is projected that, over the next decade, if nothing changes, 292,537 refracture-related hospital admissions and Emergency Department presentations and 570,000 outpatient attendances will occur, at an estimated total cost to NSW Health of AU$2.4 billion. CONCLUSION: This analysis provides a detailed picture of refractures and associated projected service utilisation and costs over the next decade in Australia's most populous state. Understanding the burden of refracture provides a foundation for evaluation of a novel statewide ORP model of care to prevent refractures in people aged ≥ 50 years.

Clinicians' experience of providing care: a rapid review.

BACKGROUND: Health care services internationally are refocussing care delivery towards patient centred, integrated care that utilises effective, efficient and innovative models of care to optimise patient outcomes and system sustainability. Whilst significant efforts have been made to examine and enhance patient experience, to date little has progressed in relation to provider experience. This review aims to explore this knowledge gap by capturing evidence of clinician experience, and how this experience is defined and measured in the context of health system change and innovation. METHODS: A rapid review of published and grey literature review was conducted utilising a rapid evidence assessment methodology. Seventy-nine studies retrieved from the literature were included in the review. Fourteen articles were identified from the grey literature search and one article obtained via hand searching. In total, 94 articles were included in the review. This study was commissioned by and co-designed with the New South Wales, Ministry of Health. RESULTS: Clinician experience of delivering health care is inconsistently defined in the literature, with identified articles lacking clarity regarding distinctions between experience, engagement and work-related outcomes such as job satisfaction. Clinician experience was commonly explored using qualitative research that focused on experiences of discrete health care activities or events in which a change was occurring. Such research enabled exploration of complex experiences. In these contexts, clinician experience was captured in terms of self-reported information that clinicians provided about the health care activity or event, their perceptions of its value, the lived impacts they experienced, and the specific behaviours they displayed in relation to the activity or event. Moreover, clinician's experience has been identified to have a paucity of measurement tools. CONCLUSION: Literature to date has not examined clinician experience in a holistic sense. In order to achieve the goals identified in relation to value-based care, further work is needed to conceptualise clinician experience and understand the nature of measurement tools required to assess this. In health system application, a broader 'clinician pulse' style assessment may be valuable to understand the experience of clinical work on a continuum rather than in the context of episodes of change/care.

Health service use in the older person with complex health needs.

Objective Effective health care for older people with complex health needs requires a diverse range of healthcare professionals working together. The Building Partnerships Framework of the New South Wales Agency for Clinical Innovation seeks to promote collaboration and integration among service providers. The aim of the present study was to inform implementation and evaluation of the Framework. Methods Data from the 45 and Up Study was linked with deaths and service data from hospitalisations and the Medicare Benefits Schedule (MBS). Participants with a hospitalisation for conditions representing 'geriatric syndrome' were allocated to a complex needs group; the remainder were allocated to a comparison group. Hospital admissions and MBS services use were modelled using log-linear Poisson regression. Results Multivariate analysis showed that the rate of hospitalisation in the 2 years following index admission for the complex needs group was 18% (95% confidence interval (CI) 1.12-1.24) greater than the comparison group and specialist physician attendance was 13% (95% CI 1.06 - 1.21) greater. The rate of general practitioner (GP) attendances was 2% (95% CI 0.97-1.07) greater in the complex needs group, but this was not statistically significant. Discussion The greater rates of hospitalisation and specialist service use, the absence of a similar finding for GP services and the prominence of the role of primary care in service integration literature, policy and strategy underscore the importance of careful planning, consultation and inclusiveness in the development and implementation of integrated care policy. What is known about the topic? Older people with complex health needs are significant consumers of primary and secondary health services and benefit from well-planned and coordinated care. What does this paper add? The findings presented here indicate that although hospitals and specialist physicians provide a significantly greater volume of services to people with complex health needs, GPs do not. Within the limitations of the present study, these findings can contribute to integrated care policy and strategy development and implementation. What are the implications for practitioners? Given the prominence of primary care in service integration literature, policy and strategy and the findings of the present study with regard to the relative level of GP involvement in the management of people with complex needs, careful policy implementation will be required to ensure GPs are able to contribute significantly to coordinated cooperation between health services.

Addressing unwarranted clinical variation: A rapid review of current evidence.

INTRODUCTION: Unwarranted clinical variation (UCV) can be described as variation that can only be explained by differences in health system performance. There is a lack of clarity regarding how to define and identify UCV and, once identified, to determine whether it is sufficiently problematic to warrant action. As such, the implementation of systemic approaches to reducing UCV is challenging. A review of approaches to understand, identify, and address UCV was undertaken to determine how conceptual and theoretical frameworks currently attempt to define UCV, the approaches used to identify UCV, and the evidence of their effectiveness. DESIGN: Rapid evidence assessment (REA) methodology was used. DATA SOURCES: A range of text words, synonyms, and subject headings were developed for the major concepts of unwarranted clinical variation, standards (and deviation from these standards), and health care environment. Two electronic databases (Medline and Pubmed) were searched from January 2006 to April 2017, in addition to hand searching of relevant journals, reference lists, and grey literature. DATA SYNTHESIS: Results were merged using reference-management software (Endnote) and duplicates removed. Inclusion criteria were independently applied to potentially relevant articles by 3 reviewers. Findings were presented in a narrative synthesis to highlight key concepts addressed in the published literature. RESULTS: A total of 48 relevant publications were included in the review; 21 articles were identified as eligible from the database search, 4 from hand searching published work and 23 from the grey literature. The search process highlighted the voluminous literature reporting clinical variation internationally; yet, there is a dearth of evidence regarding systematic approaches to identifying or addressing UCV. CONCLUSION: Wennberg's classification framework is commonly cited in relation to classifying variation, but no single approach is agreed upon to systematically explore and address UCV. The instances of UCV that warrant investigation and action are largely determined at a systems level currently, and stakeholder engagement in this process is limited. Lack of consensus on an evidence-based definition for UCV remains a substantial barrier to progress in this field.