In our latest round-up on research based articles, Caroline White looks at how peer feedback can enhance quality of care and Katherine Jones asks questions about research and physiotherapy practice.
Peer feedback can enhance quality of care
Bottom up initiatives, such as peer assessment and clinical audit, can spur on physiotherapists to improve their own practice. They may also be more effective than top down external regulation/auditing alone, suggests a feasibility study published in the online journal BMJ Open.
The researchers base their findings on a quality improvement programme, designed to boost the client centeredness, effectiveness, and transparency of services provided by 64 Dutch physiotherapists working in primary care.
The programme involved two cycles of online assessment of their own, and colleagues’, routine clinical practice, using pre-defined performance indicators. Based on specialty, 12 groups, of four to six participants each, carried out the peer assessments.
The assessments focused on record keeping and communication with clients – captured by video – followed by facilitated face-to-face group discussions of the results. Lastly, organisational performance was audited at four private clinics.
After the first peer assessment, participants designed a personal improvement plan. During the second assessment, they reflected on the improvements made.
After some initial scepticism, participants warmed to the programme, saying that it allowed for stepwise self-directed quality improvement unlike the one-time assessments provided by external regulators/auditors.
Participants felt feedback enhanced confidence in practice and increased motivation to continue peer assessment. And they said that they were more likely to follow guidelines, carry out performance measurement, and measure patient reported outcomes. The audit also increased awareness of clinical and organisational performance.
Several factors emerged as critical to success. These included adequate training in critical appraisal; sufficient time to build trust and confidence in the process; clear communication of the aims and intended outcomes from the start; competent group facilitators; and user-friendly website design. Maas MJM, et al. Feasibility of peer assessment and clinical audit to self-regulate the quality of physiotherapy services: a mixed methods study. BMJ Open 2017.
Q&A
Why is this study important?
The authors highlight that healthcare professionals and provider organisations have an ethical and professional obligation to strive for continuous quality improvement of services. A previously published review found that audit and feedback tended to effect small, but potentially important, changes in professional practice (Ivers 2012). The current study applies a bottom-up approach to quality improvement, which could have a longer lasting impact on behaviour change than external top-down regulation, the authors suggest.
What are the implications for research and physiotherapy practice?
The authors point out that self-regulation of the quality of physiotherapy services depends on the willingness of professionals and organisations to provide access to the confidential areas of their clinical practice. As such, there needs to be a ‘safe setting’ for health professionals to engage in critical peer appraisal. Further research could inform wider implementation across Dutch primary care clinics, but would also need to consider the longer-term impact on patient outcomes, say the authors.
‘This study shows how a strong collaboration between researchers and participating physiotherapists can generate context specific knowledge, which is critical to ongoing quality improvement,’ comments Ruth ten Hove, CSP Head of Development and Research. Ivers N, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews 2012. DOI: 10.1002/14651858.CD000259.pub3
- CSP research adviser Katherine Jones
Fatigue is common after a stroke, study shows
Fatigue is a relatively common symptom during the first few weeks of recovery among stroke survivors who aren’t clinically depressed, suggests a UK study.
Four to six weeks after their stroke, 371 patients from four UK stroke units were assessed for levels of fatigue, anxiety, and mobility. Their capacity to carry out routine tasks and their cognitive ability were also measured.
Those who were clinically depressed were excluded from further study, leaving 268 predominantly male (168) patients with an average age of 67. They scored an average of 4.96 on the National Institutes of Health Stroke Scale, indicating a stroke of mild to moderate severity.
Almost half (115; 43 per cent) of participants said they had experienced fatigue after their stroke, and for 71 (62 per cent) of them, this was a new symptom since their stroke.
Being in a relationship; fatigue before the stroke; lower mood; and poorer mobility were all significantly associated with a heightened risk of tiredness/low energy after the stroke.
Fatigue is ‘one of the most distressing symptoms after stroke’, yet is often overlooked, emphasise the researchers. It blights quality of life for stroke survivors and their carers, hinders rehabilitation, and delays the prospect of a return to normal life and work, they point out. Drummond A et al. The Nottingham Fatigue after Stroke (NotFAST) study: Factors associated with severity of fatigue in stroke patients without depression. Clinical Rehabilitation 2017 DOI: 10.1002/14651858.CD000259.pub3.
Comments and conclusions
- A long-term study of more than 117,000 patients who had had a total hip or knee replacement questions the increasing trend to carry out these procedures in younger age groups, say the researchers. The lifetime risk of revision surgery in patients aged 70+ was about five per cent for both sexes. But this rose to as high as 35 per cent for men in their early 50s, who were at greater risk of further surgery than similarly aged women. The average time to revision among those who had the procedure before they reached 60 was 4·4 years. Bayliss LE et al. The effect of patient age at intervention on risk of implant revision after total replacement of the hip or knee: a population-based cohort study. The Lancet 2017.
- Urinary levels of N terminal telopeptide, a by-product of bone resorption, are higher in pre-menopausal South Asian women than in their white counterparts, and are as high as those of postmenopausal women, reveals a year-long study of bone turnover in 370 women. Osteoclast cells in South Asian women might be breaking down bones faster than they are being reformed, potentially boosting susceptibility to osteoporosis in later life, suggest the researchers. Darling AL et al. Higher bone resorption excretion in South Asian women vs. White Caucasians and increased bone loss with higher seasonal cycling of vitamin D: Results from the D-FINES cohort study. Bone 2017.
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Caroline White and Katherine JonesNumber of subscribers: 2
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