Abstract
BackgroundInterest is increasing in the application of standardised outcome measures in clinical practice. Measures designed for use in research may not be sufficiently precise to be used in monitoring individual patients. However, little is known about how clinicians and in particular, multidisciplinary teams, score patients using these measures. This paper explores the challenges faced by multidisciplinary teams in allocating scores on standardised outcome measures in clinical practice.MethodsQualitative case study of an inpatient neurorehabilitation team who routinely collected standardised outcome measures on their patients. Data were collected using non participant observation, fieldnotes and tape recordings of 16 multidisciplinary team meetings during which the measures were recited and scored. Eleven clinicians from a range of different professions were also interviewed. Data were analysed used grounded theory techniques.ResultsWe identified a number of instances where scoring the patient was 'problematic'. In 'problematic' scoring, the scores were uncertain and subject to revision and adjustment. They sometimes required negotiation to agree on a shared understanding of concepts to be measured and the guidelines for scoring. Several factors gave rise to this problematic scoring. Team members' knowledge about patients' problems changed over time so that initial scores had to be revised or dismissed, creating an impression of deterioration when none had occurred. Patients had complex problems which could not easily be distinguished from each other and patients themselves varied in their ability to perform tasks over time and across different settings. Team members from different professions worked with patients in different ways and had different perspectives on patients' problems. This was particularly an issue in the scoring of concepts such as anxiety, depression, orientation, social integration and cognitive problems.ConclusionFrom a psychometric perspective these problems would raise questions about the validity, reliability and responsiveness of the scores. However, from a clinical perspective, such characteristics are an inherent part of clinical judgement and reasoning. It is important to highlight the challenges faced by multidisciplinary teams in scoring patients on standardised outcome measures but it would be unwarranted to conclude that such challenges imply that these measures should not be used in clinical practice for decision making about individual patients. However, our findings do raise some concerns about the use of such measures for performance management.
Highlights
Interest is increasing in the application of standardised outcome measures in clinical practice
From a clinical perspective, such characteristics are an inherent part of clinical judgement and reasoning [47,48]
It has been argued that outcome measures designed in research settings are not sufficiently precise to be used for the reliable monitoring of individual patients [7]
Summary
Interest is increasing in the application of standardised outcome measures in clinical practice. In part driven by this focus on outcome, there has been an exponential growth in the development of a large range of standardised outcome measures [5,6] These measures are designed to be completed by either practitioners or by patients in order to measure constructs such as impairment, functioning, participation, health status and health related quality of life. These measures are most commonly used in clinical trials of the effectiveness of care and treatment [7,8]. Such data are argued to have a role in facilitating decision making about individual patients [12], enabling clinicians to identify whether their treatments are working [13] and, at an aggregated level, to facilitate comparisons of the effectiveness between different treatments, services and institutions [14,15,16]
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