The fifteen participants (Table 1) were from a variety of healthcare backgrounds all currently employed in NHS orthotic services in the UK. The demographic information was collected in the form of a questionnaire just prior to the start of the focus group
Table 1: Professional Focus Group Demographics
Participant Number
|
Gender
(M/F)
|
Current Role
|
Years
In current Role
|
Current Use of Outcome Measure tools
(Y/N)
|
OM Tools Used
|
Relevance of Outcomes to Orthotic Practice
|
P1
|
M
|
Head of service/
Orthotist
|
15
|
Y
|
Blank
|
Very
|
P2
|
F
|
Head of service/Clinical Lead Orthotist
|
3
|
Blank
|
Blank
|
(Blank)
|
P3
|
F
|
Orthotic service manager
|
7
|
Y
|
Blank
|
Very important as we continually need to demonstrate quality
|
P4
|
F
|
Clinical Lead Orthotist
|
1
|
Y
|
Pain scales,
Activity levels
|
Very but hard in my working environment as management do not allow follow up appointments
|
P5
|
M
|
Clinical service Lead
|
9
|
Y
|
MFPI,
VAS
|
Very relevant but difficult from a time and choosing a correct measure for such a vast variety of patient groups
|
P6
|
M
|
Clinical lead Orthotist
|
15
|
Y
|
GAS,
Beighton score, FPI
|
Yes, very
|
P7
|
M
|
Clinical Lead Orthotist
|
Blank
|
blank
|
Blank
|
(Blank)
|
P8
|
M
|
Senior Orthotist
|
Blank
|
blank
|
Blank
|
(Blank)
|
P9
|
M
|
Clinical lead and head of regional orthotic services
|
1
|
Y
|
GAS, TUAG,
VAS/NRS, pain,
10MWT
|
Extremely relevant, validates our impact as a profession
|
P10
|
F
|
Principal orthotist
|
8
|
Y
|
Pain score,
Cobb angles
|
Very relevant to be able to measure what we do and show success
|
P11
|
F
|
Senior Orthotist
|
3
|
Y
|
VAS pain score,
Cobb angle
|
Very relevant to determine the success of intervention
|
P12
|
F
|
Clinical lead Orthotist
|
21
|
Y
|
Blank
|
Very
|
P13
|
F
|
Senior manager for NHS orthotics and wheelchair services
|
2
|
Y
|
Blank
|
Very, to understand evidence-based practice
|
P14
|
M
|
Lead clinical Orthotist
|
1
|
N
|
Blank
|
Yes, relevant
|
P15
|
F
|
Manager of Podiatry and Orthotics
|
8
|
N
|
Blank
|
Very important to demonstrate good practice
|
Themes and Subthemes
The researcher identified subthemes which informed the subsequent themes (Table 2).
Table 2: Themes of Professional Focus Group
Themes
|
Title of Theme
|
Subthemes
|
Theme 1
|
The Role of Goal Setting
|
Conflicting goals
Achieving agreement
Managing expectations / compromise
|
Theme 2
|
Achieving Behavioural Change
|
Users motivation
The role of education
Acceptance and satisfaction
|
Theme 3
|
The Barriers to Outcomes measurement
|
Fluctuating disease and Changing goals
Impact of multiple interventions
Time constraints
Varied case load
|
Theme 4
|
Overcoming the Barriers to Outcomes Collection
|
Role of Technology
Delegation
Snapshots
|
Theme 1: The Role of Goal Setting
Subtheme: Conflicting goals
Orthotic devices will usually be prescribed with intended goals. Participants talked of the difficulties that arise when other professionals and service users present with their own thoughts and ideas around what an orthosis can achieve:
“What's the outcome from the initial referrer because it could be totally different from what ours is” Participant 6 and
”Because what other clinicians feel an orthosis does and what we are telling them it actually does are sometimes very different…You've got the three different concerns you've got the referrers you've got the patients and then you've got ours” Participant 1
These differing goals between parties were also discussed when considering the challenges of using outcome measures (OM’s):
“We have been using the GAS lite system which relies on you getting what the patient wants, what the orthotist wants and combining the two…the problem is when we actually started doing that, the objectives the patient wanted and what the orthotist wanted weren’t even vaguely close and the perception coming through with the referral and with the referrer didn’t match up with either of them either” Participant 7
Participants attributed these differing goals, particularly for service users, to differing priorities. They felt the important goals for clinicians often were not the important goal for service users:
“we are all guilty about still pursuing to make them safer on their feet…make sure we are reducing the level of risk but actually at the end of the day it’s still not the patient’s goal” Participant 7
Participants talked of identifying goals at the outset of treatment as an important start towards outcome measurement. However, the different opinions (themselves, the referrer and the patient) on what the intended goal should be and hence what the OM could be was a difficulty.
Subtheme: Achieving agreement
These differing goals meant there was a need for discussion with service users. One participant described the need to establish a joint goal prior to starting orthotic treatment:
“We see the patients…they’ve got their own ideas, they talk to friends, their families…it’s getting the marriage of those two things” Participant 6
The other participants confirmed, describing joint goals with patients as key to successful outcomes:
“well the question is… can you achieve an outcome that the patient understands what’s wrong with them…why the clinician is suggesting what their suggesting and you’ve agreed on what the goal will be” Participant 5 and,
“It has to meet the patients and the healthcare professional’s expectations of what it aims to do” Participant 2
Participants described the need for a process of joint decision making for goals that resulted in an agreed treatment plan.
Subtheme: Managing Expectations/compromise
Linked to goal setting, participants described a need to establish and identify patient expectations prior to treatment:
“Is the patient’s objective to reduce pain, prevent falls, walk better when you know its managing those expectations” Participant 13,
They indicated the need to compromise and readjust the patient’s expectations:
“The whole point of an orthosis is to achieve a successful clinical function, but if we have actually provided them with something and they are happy… is that really the ultimate goal, even though it may not be as functionally or as clinically appropriate?” Participant 1.
and
“You’re going to make something that’s not going to be fantastic but that will fit in the shoes that they wear and will be usable” Participant 5
In instances where expectations were considered impossible to meet, questions were posed as to whether treatment was appropriate at all:
“Because if you establish at the front end that actually the two [goals] won’t ever meet and we’re not going to satisfy the patients expectations why order the product and pursue any further” Participant 1,
Participants expressed the need for some level of compromise when addressing patient expectations.
Theme 2: Achieving Behavioural Change
Subtheme: Users motivation
Successful outcomes were described as an orthosis being “usable” with motivation being a huge factor in engagement and hence a successful outcome,
“If you have got someone that’s determined enough to get back to sport then they will wear that massive knee brace, because it means they can go play football again” Participant 2 or,
“…if its spinal bracing they can get out of bed” Participant 10
As part of this participants acknowledged the difficulties patients faced in order to change behaviour to use an orthosis:
“I work a lot with neuro patients and I can see they tip or fall or have a foot drop, and I’ll say well we’ll put an intervention in and that stopped you tripping and you’re not going to fall, but to that patient them falling isn’t a big enough problem for them to change their footwear” Participant 2
Participants felt that the cosmetic appearance of an orthosis and the heath behaviour change often required to utilise the device could have a significant impact on successful outcomes of care.
Subtheme: The role of education
Participants described their role of empowering patients with information to understand the recommendations being made in order to make decisions on their care:
“…the most powerful tool we have is the ability…to educate our patients…help them understand what's going on and what your aims are and therefore why you're going to design something in the way you're going to design it…” Participant 5 and,
“My patients are all very happy but some of them don’t achieve the goal they wanted to achieve, but they’re still very happy because they understood what we were trying to achieve…they felt a part of the process” Participant 5
This education was also described as an important step in obtaining informed consent:
“I think it’s very much like surgery…I mean the consultants would …talk through the risks with the patients and say this is a possible outcome you know. We have the same conversations in orthotics and then based on that education, that discussion you come up with a prescription” Participant 9
And preparing patients for potential orthotic treatment and the health behavioural changes this could involve:
“We have an early intervention rehab team…they will refer into my orthotic clinic and part of that is more about advice only…they are educated… they are more likely to have successful outcomes… they know what to expect, they know what their options are” Participant 1
A process of educating patients was viewed as a way of making them feel involved in their care, almost empowered to decide to utilise the intervention being recommended.
Subtheme: Acceptance and Satisfaction
Participants described the importance of the patient’s eventual acceptance and use of a device as an important outcome:
“Something that the patient will wear and use, if it goes into a cupboard it’s a useless orthosis no matter how good it is” Participant 7
This focus on patient satisfaction and a “usable” device also appeared to influence the types of OM tools that participants would use in practice:
“Patient satisfaction from start to finish with their journey and that for me...that’s the one I go to because my patients are happy they’ve enjoyed their journey they’ve understood their journey they’ve had a good outcome. I'm happy” Participant 5 and,
“...we looked into outcomes but it’s very much a case of we still use the review or the return of the patient coming back to then think have we achieved it” Participant 1 and
“That’s a happy person and we have achieved what we wanted to” Participant 13
A service user utilising an orthotic device and satisfied with their care was seen as an important outcome of treatment. Because of this, participants agree that the use of patient reported outcome measures (PROM’s) were an appropriate way to measure outcomes.
Theme 3: The Barriers to Outcomes Collection
Subtheme: Fluctuating disease and changing goals
Participants indicated the pattern of different chronic diseases as the most challenging factor:
“What can happen especially with chronic disease is those goals change” Participant 6 and,
“…some of them are chronic, like RA condition…you know on that day might be ok but then after, or an hour after it might not, so it’s really tricky” Participant 13
Participants felt that patients’ needs can change from day to day. and explained how this could make it difficult to establish and maintain goals of care and impact on the outcomes of treatment. Participants also described how patients themselves could change the goals set at initial assessment:
“… a lot of our patients are just long-term chronic patients and their needs change for all sorts of reasons, which can be vocational as well as their disease progression, you know they can change because they decided to take up bowls which is really good for them socially, so we actually need to adapt to that” Participant 2
Participants discussed how chronic disease can often mean changing goals for treatment, posing difficulties for outcome measurement considering those set at the start off treatment may change throughout the course of treatment. They also highlighted how patients themselves change goals, with the introduction of new hobbies or new expectations of care during treatment.
Subtheme: Impact of multiple interventions
A challenge of managing patients with chronic disease was multidisciplinary management which will often involve several different treatment modalities and a variety of different health professionals:
“I think those that are diabetic change things considerably really…there are so many other factors that will determine that outcome it’s very hard to, I think, pin down and hard to measure that diabetic success based on other variables that you don't have control over, compliance, diabetic control, vascular supply…” Participant 5 and,
“And on the back of that it's a case of a lot of orthosis, especially for diabetic care are about maintenance and prevention and its quite hard to measure whether it’s successful other than they haven’t re-ulcerated. But they might not have re-ulcerated for many other factors.” Participant 1
It is clear that orthotic management for patients with chronic disease was rarely provided in isolation and so potential benefits could not always be attributed to the orthosis alone. This creates a problem when selecting a tool to measure the specific outcomes delivered by orthotic care.
Subtheme: Time constraints
Participants described their experience of using OM tools in practice as difficult due to the length of time to complete them:
“I use…the Manchester foot pain disability index; don’t use it routinely as it takes too long” Participant 5 and,
“I’ve used this OPUS before…this was the worst outcome measure because of the length of it” Participant 9
Other participants noted the same issues when presented with OM tools the researcher had identified from a review of the literature:
“The only problem with both of these, they are massive to do…” Participant 7 and
“They are too lengthy to feel like they are practical within a 20/30 minutes appointment slot” Participant 1
One participant also described the practical limitations of clinical setting:
“I think there’s clinical ones out there, like the timed up and go and 10 metre walk test that could be used, not everywhere as some of us are in cupboards…Who’s got a ten-metre walkway?” Participant 9
Participants indicated that they felt current OM tools were not practical for use in their everyday orthotic practice and setting. They indicated the average time slot provided for assessments did not allow for the extra task of OM collection. They felt a number of tools were too lengthy and indicated that they felt even service users would find this an inhibiting factor.
Subtheme: Varied case load
Participants also described difficulties associated with identifying the most appropriate OM from the vast number available for the various pathologies they treated:
“There’s a certain amount of apathy with me in the fact that I'm doing a lot of other things…and so when that patient comes through the door who fits the bill for the outcome measure…I’ve ran out of time” Participant 1 and
“Because within a day, the day starts, and you know you can have your rheumatoid one moment and something else the next, you can’t have all the questionnaires at reception for ‘what type of patient are you?’” Participant 5 and,
“That’s what’s often the problem isn’t it. It’s a different outcome for everybody” Participant 2
The diversity of orthotic service users made it difficult for participants to identify the right tool at the right time and created barriers to the routine use.
Theme 4: Overcoming the Barriers to Outcome Collection
Sub theme – What we need
The participants expressed a preference or need for OM tools that were quick and easy to use:
“We need a scale that allows us to have three questions; GAS lite gives us that straight away” Participant 7 and
“The most effective thing in the vast majority of the population is a really simple text message with three questions” Participant 7
Participants favoured the idea of generic tools, applicable for the majority of service users:
“When we looked at them there was such a huge variety of different outcome measures and we couldn’t find one that gave us a clinical outcome that we could put across the board” Participant 10
This appeared to link to the overall preference of satisfaction questionnaires:
“So that's why it’s always good to have the service one. How were reception staff? Did you feel like you were listened to? Where you given enough time? Did you feel like all your questions were answered? Did you get something that was usable? Do you find that it helps you? Are you happy with the service?” Participant 5
Participants wanted tools that were manageable to use within the time frames they were given. This appeared to lead to a preference for tools that are simple and quick to complete and could incorporate technology for ease of collection. This is why a number of validated tools were not being used by participants, with a preference towards satisfaction questionnaires completed by patients themselves.
Subtheme: Role of Technology
The traditional paper format OM was seen as a barrier to their use:
“the problem is you’ve got all these outcome measures that are stuck in these cupboards and written on Post-it notes, in files, it's all just lost” Participant 9
Technology was suggested as a method in aiding OM tool selection:
“It’s all paper again. We’re miles off technology, you could have all this stuff on an iPad, it’s very easy, you could email it to patients” Participant 9
However, participants talked of their frustrations related their current IT systems that did not support this:
“The IT systems make or break a lot of this as far as measuring because…can’t retrieve as a report…our IT system doesn’t do it” Participant 1
IT and technology were seen as a way of addressing not only the data burden but also the selection and administration of appropriate OM tools, but current IT systems did not facilitate this.
Subtheme: Delegation
To tackle issues related to time constraints participants talked of delegation of OM to others:
“We’re using telephone reviews…telephone reviews are being done by our orthotic assistant” Participant 11 and
“I also am exploring whether it has to be an orthotist that makes that phone call, whether someone else can make that phone call to ask some risk based questions which would then either send the patient back through triage and for review or we would say that’s a happy person and we have achieved what we wanted” Participant 13
Lack of clinical time meant that some participants had been driven to find alternative ways of collecting OM data.
Subtheme: Snapshots
Another way in which these barriers were addressed was via the use of what one participant described as ‘snapshots’:
“I use…the Manchester foot pain disability index… we will do a full week or a snapshot…it’s a bit labour intensive for that week but it’s only that week” Participant 5 and,
“So, what we decided to do is to have 6 months on an area of a group of patients with one outcome measure for that and then to move on to another cohort of patients and probably with a different outcome measure” Participant 10 also,
“We are recording pain scores just for insole patients at the moment” Participant 12
There was agreement between participants that this was a way of overcoming some of the earlier identified barriers:
“I think taking the (Participant name removed) point earlier though if you did some random sampling maybe in a quota and ran 20, 30, 40, 50 patient, whatever the sample size, a group of your service, you could do a modelling thing” Participant 13
Participants agreed on the importance of OMs (both objective clinical measures and patient reported outcome measures) for orthotic practice and looked at novel ways in which they could include its collection through snapshots, i.e. specific patient groups, pathologies or outcomes over a specific time period meaning that data collection was more manageable.