Benchmarking quality of care using patient reported outcome measure data for patients presenting with musculoskeletal conditions in primary care GP practices.

BACKGROUND: Patient Reported Outcome Measures (PROMs) evaluate health status from a patient perspective. They can be used to support care at a patient level but also collectively to review quality of care across care providers. Vast amounts of patients with musculoskeletal (MSK) conditions present to General Practice (GP) primary care practitioners each year. Variation in patient outcomes in this setting however has not been reported. OBJECTIVE: To identify variation in patient outcomes measured using the musculoskeletal health questionnaire (MSK-HQ) PROM for adults presenting to 20 GP practices in the UK with MSK conditions. METHODS: A secondary analysis of the STarT MSK cluster randomised controlled trial dataset. A standardised case-mix adjustment model, adjusting for condition complexity co-variates, was used to calculate predicted 6-month follow-up MSK-HQ scores, and used to compare adjusted and un-adjusted health gain (n = 868). Patient MSK-HQ change outcomes were aggregated to practice level and boxplots used to display outlier GP practices for un-adjusted and adjusted outcomes. RESULTS: Substantial variation in patient outcomes was seen across the 20 practices, even after case-mix adjustment, with mean change in MSK-HQ scores ranging from 6 to 12 points. Boxplots displaying un-adjusted outcomes showed one negative GP practice outlier and two positive outliers. However, the boxplots displaying case-mix adjusted outcomes showed no negative outliers, with two practices remaining as positive outliers, and one practice additionally becoming a positive outlier. CONCLUSION: This study showed a two-fold GP practice variation in patient outcomes measured using the MSK-HQ PROM. To our knowledge it is the first study to demonstrate that (a) a standardised case-mix adjustment method can be used to fairly compare patient health outcome variation in GP care, and (b) that case-mix adjustment changes benchmarking findings with regards to provider performance and outlier identification. This has important implications for identifying best practice exemplars and thereby helping to improve the quality of MSK primary care in the future.

Benchmarking community/primary care musculoskeletal services: A narrative review and recommendation.

INTRODUCTION: High quality data on service performance is essential in healthcare to evidence efficacy, efficiency, and value. There remains a paucity of publicly reported data in community and primary care musculoskeletal (MSK) services. There is also a lack of guidance on which metrics MSK services should be collecting and reporting, and how this data could be used to directly improve patient outcomes, experiences, and value. METHOD: A narrative review of the evidence around benchmarking MSK services was undertaken with a focus on how to develop routine data collection within community/primary care settings, and how to develop benchmarking capabilities for the future, looking towards a national MSK audit. This evidence was triangulated with the findings from recent MSK data studies undertaken by the authors and emerging UK policy and guidance in this area. RECOMMENDATIONS: To enable MSK benchmarking services need to collect consistent, standardised outcomes and, therefore, we have developed a recommendation on a minimum MSK 'core outcome set' of Patient Reported Outcome Measures (PROMs) and Patient Reported Experience Measures (PREMs) (PROMs: MSK-HQ, NPRS, WPAI; PREMs: National MSK PREM). In addition, we make recommendations on the use of a standardised evidence-based method for case-mix adjustment and outlier identification (using the following baseline demographics and clinical factors; age, sex, ethnicity, pain site, comorbidities, duration of symptoms, previous surgery, previous pain episodes), alongside considerations on how this data should be integrated and reported within NHS systems. CONCLUSIONS: Capturing high quality MSK data in a standardised, consistent, and sustainable way is a significant challenge. Policy holders, commissioners, managers, and clinicians need to be realistic with expectations, and take time to explore barriers to implementation including, funding, digital infrastructure/intra-operability, data sharing/governance, digital literacy, and local/national leadership. Next steps include developing a national MSK audit programme to provide a benchmarking model to support continuous improvements in care quality for patients living with MSK conditions.

Costing Methodology and Key Drivers of Health Care Costs Within Economic Analyses in Musculoskeletal Community and Primary Care Services: A Systematic Review of the Literature.

Background: Identifying variation in musculoskeletal service costs requires the use of specific standardized metrics. There has been a large focus on costing, efficiency, and standardized metrics within the acute musculoskeletal setting, but far less attention in primary care and community settings. Objectives: To (a) assess the quality of costing methods used within musculoskeletal economic analyses based primarily in primary and community settings and (b) identify which cost variables are the key drivers of musculoskeletal health care costs within these settings. Methods: Medline, AMED, EMBASE, CINAHL, HMIC, BNI, and HBE electronic databases were searched for eligible studies. Two reviewers independently extracted data and assessed quality of costing methods using an established checklist. Results: Twenty-two studies met the review inclusion criteria. The majority of studies demonstrated moderate- to high-quality costing methods. Costing issues included studies failing to fully justify the economic perspective, and not distinguishing between short- and long-run costs. Highest unit costs were hospital admissions, outpatient visits, and imaging. Highest mean utilization were the following: general practitioner (GP) visits, outpatient visits, and physiotherapy visits. Highest mean costs per patient were GP visits, outpatient visits, and physiotherapy visits. Conclusion: This review identified a number of key resource use variables that are driving musculoskeletal health care costs in the community/primary care setting. High utilization of these resources (rather than high unit cost) appears to be the predominant factor increasing mean health care costs. There is, however, need for greater detail with capturing these key cost drivers, to further improve the accuracy of costing information.

Predictors of functional outcome in musculoskeletal healthcare: An umbrella review.

BACKGROUND: Multiple cohort and systematic review studies exist, reporting independent predictive factors associated with outcome in musculoskeletal populations. These studies have found evidence for a number of "generic" factors that have been shown to predict outcome across musculoskeletal patient cohorts. This review provides a higher level review of the evidence with a focus on generic patient factors associated with functional musculoskeletal outcome with a view to informing predictive modelling. OBJECTIVES: (a) Identify patient factors found to have evidence to support their association with functional outcome, and (b) review these findings across body areas/conditions to identify generic predictive factors. DATABASES AND DATA TREATMENT: Electronic databases of MEDLINE, AMED, EMBASE, CINAHL and Cochrane were searched for eligible studies. Two reviewers independently extracted data and assessed quality using an established checklist for umbrella reviews. RESULTS: Twenty-one systematic reviews met inclusion criteria, all were of moderate/high quality. Six independent predictors were found to have strong evidence of association with worse musculoskeletal functional outcome across anatomical body sites (worse baseline function, higher symptom/pain severity, worse mental well-being, more comorbidities, older age and higher body mass index). Longer duration of symptoms, worse pain coping, presence of workers compensation, lower vitality and lower education were also found to have moderate evidence of association with worse functional outcome across body sites. CONCLUSIONS: This study identifies a number of factors associated with musculoskeletal functional outcome. The generic predictive factors identified should be considered for inclusion into musculoskeletal prognostic models, including models used for case-mix-adjustment of patient reported outcome measure data. SIGNIFICANCE: This article identifies "generic" patient factors that predict functional outcome (measured using Patient Reported Outcome Measures (PROMs)) across musculoskeletal conditions. Findings provide support for the development and content of generic musculoskeletal prognostic models including models used to case-mix adjust PROM data for baseline complexity. Generic musculoskeletal models and functional PROMs would facilitate more feasible comparison and benchmarking of musculoskeletal services in order to identify variation and address health inequalities.

The validity and accuracy of clinical diagnostic tests used to detect labral pathology of the hip: a systematic review.

Acetabular labral tears are an area of increasing interest to clinicians involved in the diagnosis of musculoskeletal complaints of the hip. This review systematically evaluated the evidence for the diagnostic accuracy and validity of reported symptoms, physical examination and imaging in this complex population. Studies published in English prior to May 2010 were included. One reviewer searched information sources to identify relevant articles. Two reviewers independently assessed studies for inclusion, extracted data and evaluated quality using the Quality Assessment of Diagnostic Studies Tool. Twenty one studies were included. Meta-analysis was limited owing to heterogeneity between studies. Results showed Magnetic Resonance Arthrography to consistently outperform Magnetic Resonance Imaging. Computerised Tomography also showed high accuracy levels for the few studies identified. Studies investigating physical tests were of poor quality demonstrating a need for further research in this area. Symptoms likely to be present in patients presenting with acetabular labral tears were found to be anterior groin pain and mechanical hip symptoms; however, additional good quality studies are needed to consolidate findings.