Healthcare delivery is currently experiencing a significant change from what was traditionally a volume-based model, to one that is based on the value of healthcare delivery (Squitieri et al, 2017). The aim of a value-based healthcare (VBHC) delivery model is to improve patient safety, quality of care and cost-efficiency of interventions (Elf et al, 2017) by: effectively engaging consumers (Wilson et al, 2016); improving care coordination (Chen et al, 2013); and, endeavouring to reduce purchasing costs (Haywood, 2010).
VBHC considers the benefits of care to patients relative to the costs of achieving these (eg staff, consumables). At a policy level, this involves a cost-utility analysis which, while more complex than standard economic analysis, has been adopted as core business for many healthcare systems, due to a high rate of healthcare inflation, in the context of finite resources (Brown et al, 2003). At the foundation of VBHC delivery is evidence-based medicine, which is the implementation of care that is supported by high-level evidence, carried out by skilled/expert clinicians, taking into account patient values and the perceived value of care provided (Brown et al, 2003; Svet al, 2000). For example, a high-cost procedure that demonstrates little benefit is not an efficient use of funds, while cost-saving poor-quality care is similarly inefficient (Porter and Teisberg, 2006). In practice, this has led to Value-Based Insurance Designs (relevant for primarily privatized health systems), which are aimed at minimizing both under-use and over-use of healthcare systems (Fendrick et al, 2010). Public health systems have similarly begun to implement this concept of value in their national systems, such as use in the assessment of pharmaceuticals prior to insurance (public or private) subsidization (Claxton et al, 2008).
To assess the impact of VBHC delivery, health outcomes (both clinical and patient-reported) must be: (i) measured; (ii) reported and compared; and (iii) used to inform quality improvement processes (van Deen et al, 2015). Patient-reported measures have, therefore, become vital in determining the value of healthcare, as patients are at the centre of understanding and defining what benefits are achieved (Deshpande et al, 2011). Typically, these benefits have been conceptualized and reported either as (i) patient-reported outcome measures (PROMs), defined as patients' self-reporting of aspects of their health status and well-being, or (ii) patient-reported experience measures (PREMs), defined as patients' description of what care they received, and how that care was provided (Tremblay et al, 2015). In practice, these measures are not only used to inform cost-utility analysis by assessing changes in, and cost of, quality-adjusted live years (QALY) (ie the health benefit in procedures such as surgery) (Coronini-Cronberg et al, 2013), but also to provide ongoing feedback during routine care (eg experiences of symptoms during cancer treatment) (Howell et al, 2013).
List of abbreviationsCSH: CINAHL Subject HeadingsMeSH: Medical Subject HeadingsPVAD: Peripheral Venous Access DevicePREM: Patient Reported Experience MeasurePRISMA-ScR: Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping ReviewsPROM: Patient Reported Outcome MeasureRCT: Randomized Controlled TrialVBHC: Value Based Health Care
As health systems transition to VBHC, PROMs and PREMs have been adopted as key performance measures, resulting in an influx of various ‘generic’ and ‘disease/dimension’ specific tools (Deshpande et al, 2011). However, the use and quality of PROMs and PREMs vary significantly (Frost et al., 2007). In many cases, these measures have not been validated, nor have they had patient/consumer input during development (Frost et al, 2007). Despite this, evidence suggests that reliable and well-utilized PROMs, can result in healthcare improvement, specifically related to clinician–patient communication, treatment-response assessment, and early detection of complications (Chen et al, 2013).
Vascular access is an area for which valid and reliable PROMs and PREMs are particularly needed to enable care quality improvement. It is estimated that 70% of all patients undergoing treatment in a tertiary facility will require a peripheral venous access device (PVAD) (Zingg and Pittet, 2009). Despite their ubiquity, both insertion failure and subsequent PVAD failure remain high. It is estimated that between 14-35% of patients will require two or more attempts prior to PVAD insertion (Carr et al, 2016; Cuper et al, 2012); and 32-41% of PVADs fail prior to completion of therapy, often requiring re-insertion (Abolfotouh et al, 2014; Marsh et al, 2018; Rickard et al, 2018). The negative physical and emotional impacts of these healthcare failures are broad, ranging from immediate effects (eg, missed or delayed treatment; pain associated with PVAD re-insertion), to long-term effects (eg, undermined vessel health; patient anxiety and distrust) (Cooke et al, 2018; Larsen et al, 2017).
Anecdotal evidence suggests that commonly used generic PROMs (eg EuroQual-5D) (Herdman et al, 2011) and PREMs (eg HCAHPS) (Giordano et al, 2010) may not be adequate for use within this context; and further research is required to ensure the use of purpose-built vascular access PROMs and PREMs, developed in partnership with consumers. The aim of this scoping review is to establish the existence of tools/instruments/surveys used to measure self-reported outcomes and experiences related to PVADs and synthesize and compare how these tools are used in the context of both adult and paediatric settings.
Methods
Review questions/objective
- What tools and instruments are currently used to measure patient-reported outcomes, experiences and satisfaction for PVADs?
- What similarities and dissimilarities exist between selfreporting measures/tools?
- What are the characteristics of the populations for which self-reporting has been measured/studied?
Searches
A systematic search of the literature will be conducted using electronic medical databases, including: MEDLINE (Ovid); CINAHL Complete (EbscoHost); PubMed (NCBI); Scopus (Elsevier); Embase (Elsevier); and the Cochrane Central Register of Controlled Trials. Searches will systematically use appropriate subject headings in the databases (see Table 1).
Table 1. Search strategy
| MeSH/CSH terms: [‘Catheterization, Peripheral’] (explode), orKeywords: ‘peripheral venous’; ‘venous catheter’; ‘intravenous’; ‘cannula’; ‘PIV’ or ‘PVC’. ANDMeSH terms: [‘Patient Reported Outcome Measures’]; [‘Self Report’]; [‘Patient Outcome Assessment’] (explode); [‘Treatment Outcome’] (explode); [‘Quality of Life’] (explode); or [‘Patient Satisfaction’] (explode), orCSH terms: [‘Outcomes (Health Care)’] (explode); or [‘Patient-Reported Outcomes’], orKeywords: ‘experience’; ‘satisfaction’; ‘opinion’; or ‘perspective’. ANDMeSH terms: [‘Surveys and Questionnaires’] (explode); [‘Health Care Surveys’] (explode); [‘Health Surveys’] (explode); or [‘Visual Analog Scale’], orCSH terms: [‘Surveys’] (explode); or [‘Research Instruments’] (explode), orKeywords: ‘questionnaire’; ‘survey’, ‘instrument’; ‘tool’; ‘likert’; or ‘numerical rating scale’; or ‘measure’. ANDMeSH/CSH terms: [‘Tertiary Healthcare’] (explode); [‘Tertiary Care Centers’] (explode); [‘Inpatients’] (explode); [‘Hospitals’] (explode) or [‘Episode of Care’], orKeywords: ‘patient’; or ‘consumer’. |
Inclusion criteria
Experimental (eg randomized controlled trials [RCT], including quasi-experimental) and observational (eg cohort) studies published, in English, after 1990, will be eligible for inclusion if they (i) include a survey, instrument or tool that is designed to (ii) collect outcome, experience and/or satisfaction data, relating to (iii) PVAD insertion, care, maintenance and/or removal (including relating processes and features including education, and PVAD attachments/related equipment), from (iv) adult and paediatric participants. Studies will also be eligible if a relevant instrument/tool has been developed, but not yet tested. In addition, the reference list of retrieved studies will be reviewed to identify further eligible reports. Following screening, full text articles of eligible titles will be retrieved and screened for inclusion.
Exclusion criteria
Studies prior to 1990 will be excluded to ensure included tools and measures reflect modern healthcare practices. Further exclusion criteria will be grey literature, studies related to healthy volunteers, and hypothetical-only scenario surveys (eg vignettes).
Study selection
Two reviewers will independently assess titles and abstracts for study inclusion against the pre-established inclusion and exclusion criteria, using Endnote X7 software. Duplicates will be removed. Selected titles will be compared for congruence; in the case of any disagreements, an experienced third reviewer will be consulted for final decision. The reason for title exclusion will be documented.
Data extraction
Following study selection, two independent reviewers will extract data using a purpose-built form. Any disagreement will be resolved by a third reviewer. A flowchart presenting studies excluded at a title, abstract and full-text level, will be presented in the scoping review, as per the ‘Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews' (PRISMA-ScR) (Tricco et al, 2018). Extracted data will include: study design (eg RCT); population (eg adult, emergency, country); study intervention (if relevant); and details of the PROM, PREM, and/or satisfaction component of the study (eg primary versus secondary outcome of interest). Further details of the domains (eg quality of life) and individual attributes (eg self-reported pain), scale (eg Likert, numerical rating scale [NRS]), and collection methods (eg prospective questionnaire, number of questions) of selfreported measures, will be extracted.
In alignment with the aim of this scoping review, the primary focus of the reviewer data extraction will be: (i) what- (health aspect of interest); and (ii) how (tool/measure used) self-reports of PVAD insertion, care, maintenance, and removal, are collected; sample sizes, results of self-reported measures, and effects of interventions, will not be extracted.
Data analysis
Included studies will be presented using descriptive statistics. An ‘Evidence Gap Map’ (Snilstveit et al, 2016) will be formed to further highlight grouped themes of the current state of the evidence; descriptive (themed) tables will present data using three dimensions including: (i) the health or experience aspect of interest, (ii) the tool/measure used, and (iii) a visual representation (eg bubble, sized) of the number of times this appeared in the included studies (Snilstveit et al, 2016). Adult and paediatric results will be compared for similarities and presented either together or separately, based on appropriateness.
Discussion and dissemination
The use and dissemination of reliable patient self-reported outcomes and experience measures to inform future PVAD research and quality improvement strategies is essential in enabling a new focus on value and prioritization of consumer inclusion in the care and maintenance of vascular access devices. This scoping review will be the first to explore what and how PVAD-specific patient self-reported measures are currently used to assess outcomes, experiences and satisfaction in modern-day healthcare settings.
The authors will ensure wide dissemination of the scoping review findings by ensuring timely publication in a widely accessible peer-reviewed journal, and through scientific meeting presentations (locally and internationally), aimed at both vascular access and VBHC-interested parties.
Furthermore, results will be disseminated and discussed with local district health VBHC delivery teams to inform future processes and priorities.