Fifteen participants took part in the study (Table 1) and were all currently employed in NHS orthotic services in England. Those in management positions had clinical experience, and all stated that most of their practice focused on footwear. Eighty percent [n=12] of the participants stated that the measurement of outcomes was relevant to practice but only 40% [n=6] used them in practice.
Table 1: Participant Demographics
Participant Number
|
Gender
(M/F)
|
Current Role
|
Years
In current Role
|
P1
|
M
|
Head of Service/
Orthotist.
|
15
|
P2
|
F
|
Head of Service/
Clinical Lead Orthotist.
|
3
|
P3
|
F
|
Orthotic Service Manager.
|
7
|
P4
|
F
|
Clinical Lead Orthotist.
|
1
|
P5
|
M
|
Clinical Service Lead.
|
9
|
P6
|
M
|
Clinical Lead Orthotist.
|
15
|
P7
|
M
|
Clinical Lead Orthotist.
|
No response
|
P8
|
M
|
Senior Orthotist.
|
No response
|
P9
|
M
|
Clinical Lead/Head of Regional Orthotic Services
|
1
|
P10
|
F
|
Principal Orthotist.
|
8
|
P11
|
F
|
Senior Orthotist.
|
3
|
P12
|
F
|
Clinical Lead Orthotist
|
21
|
P13
|
F
|
Senior Manager for NHS Orthotics and Wheelchair Services
|
2
|
P14
|
M
|
Clinical Lead/Orthotist
|
1
|
P15
|
F
|
Manager of Podiatry and Orthotics
|
8
|
Themes and Subthemes
The researcher identified subthemes which informed the subsequent themes (Table 2).
Table 2: Themes from the 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 Measuring Outcomes.
|
Fluctuating disease and changing goals.
Impact of multiple interventions.
Time constraints.
Varied case load.
|
Theme 4
|
Overcoming the Barriers to Using Outcome Measures.
|
What We Need.
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.” P6
” 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.” P1
These differing goals between parties were also discussed when considering the challenges of using outcome measures:
“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.” P7
Participants attributed these differing goals, particularly for patients, to differing priorities. They felt the important goals for clinicians often were not the important goal for patients:
“…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.” P7
Participants talked of identifying goals at the outset of treatment as an important start towards the measurement of outcomes. However, the different opinions (themselves, the referrer and the patient) on what the intended goal should be is vital in maximising the potential for a positive outcome.
Subtheme: Achieving agreement
These differing goals meant there was a need for discussion with patients. 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.” P6
The other participants confirmed this, describing agreement of 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.” P5
“It has to meet the patients and the healthcare professional’s expectations of what it aims to do.” P2
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 it is managing those expectations.” P13
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?” P1
“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.” P5
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.” P1
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.” P2
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” P2
Participants also felt that the cosmetic appearance may detract from the clinical goals,
“… that’s still the clinical measure and your expectations of what you want for that patient …reduce the Falls …but actually at the end of the day it’s still not the patient’s goal and cosmesis is the big one for that especially if it’s about clothing choices”. P1
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…” P5
“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.” P3
Preparing patients for their potential orthotic treatment could involve education before referral for example:
“We have an early intervention rehab team…they will refer into my orthotic clinic and part of that is …they are educated… they are more likely to have successful outcomes… they know what to expect, they know what their options are.” P1
A process of educating patients was viewed as a way of making them feel involved in their care and in the context of their own needs, expectations and personal goals. Although this may not result in achieving maximum health outcomes, it was seen as an important factor in patient engagement and use of the orthoses.
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.” P7
This focus on patient satisfaction and a “usable” device also appeared to influence the types of outcome measure that these participants would use in their practice. However, they expressed a preference for measures of satisfaction:
“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 if they’ve enjoyed their journey…they’ve had a good outcome. I'm happy.” P5
“...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.” P1
A patients' use of the orthosis and being satisfied with their care were seen as important outcomes of treatment. Because of this, participants agreed that the use of outcome measures that included satisfaction would be preferable.
Theme 3: The Barriers to Measuring Outcomes
Subtheme: Fluctuating disease and changing goals
Participants indicated the pattern of different chronic diseases as the most challenging factor in the measurement of outcomes:
“What can happen especially with chronic disease is those goals change.” P6
“…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.” 13
Participants also described how patients themselves could change the goals set at initial assessment and highlighted how patients themselves change goals, with the introduction of new hobbies or new expectations of care during treatment:
“… 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.” P2
Subtheme: Impact of multiple interventions
Multidisciplinary management of patients with chronic diseases was seen as a challenge. This 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 success based on other variables that you don't have control over, compliance, diabetic control, vascular supply…” P5
“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.” P1
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 orthoses alone. This creates a problem when selecting a specific outcome measure.
Subtheme: Time constraints
Participants described their experience of using outcome measurement 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.” P5
“I’ve used OPUS before…this was the worst outcome measure because of the length of i.t” P9
Other participants noted the same issues when discussing some outcome measures:
“The only problem with both of these, they are massive to do…” P7
“They are too lengthy to feel like they are practical within a 20/30 minutes appointment slot” Participant 1
Participants indicated that these outcome measures 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. They felt a number of outcome measures were too lengthy and indicated that patients would find this an inhibiting factor.
Subtheme: Varied case load
Participants also described difficulties associated with identifying the most appropriate outcome measures 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.” P1
“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?” P5
“That’s what’s often the problem isn’t it. It’s a different outcome for everybody.” P2
The diversity of patient groups made it difficult for participants to identify the right outcome measure at the right time and this was a barrier to routine use.
Theme 4: Overcoming the Barriers to Using Outcome Measures
Sub theme – What we need
The participants expressed a preference or need for outcome measures 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.” P7
“The most effective thing in the vast majority of the population is a really simple text message with three questions.” P7
Participants favoured the idea of generic measures, 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.” P10
This appeared to link to the overall preference for patient 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?” P5
Participants wanted measures that were manageable to use within the time frames they were given. This appeared to lead to a preference for those that are simple and quick to complete and could incorporate technology for ease of collection. This is why a number of validated outcome measures were not being used by these participants, with a preference towards satisfaction questionnaires completed by patients themselves.
Subtheme: Role of Technology
The traditional paper format of outcome measures 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.” P9
Technology was suggested as a method in aiding 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.” P9
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.” P1
Technology was seen as a way of addressing not only the data burden but also the selection and administration of appropriate outcome measures, but the current IT systems did not facilitate it.
Subtheme: Delegation
To tackle issues related to time constraints participants talked of delegation of measuring outcomes to others:
“We’re using telephone reviews…telephone reviews are being done by our orthotic assistant.” P11
“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.” P13
Lack of clinical time meant that some participants had been driven to find alternative ways of collecting outcome data.
Subtheme: Snapshots
Another way in which barriers were addressed was 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.” P5
“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.” P10
There was agreement between participants that this was a way of overcoming the barriers:
“I think …if you did some random sampling maybe in a quota and ran 20, 30, 40, 50 patients, whatever the sample size…you could do a modelling thing.” P13
Participants agreed on the importance of outcome measures for orthotic practice and looked at novel ways in achieving its collection through ‘snapshots’, focussing on specific patient groups or pathologies over a short time meaning that data collection was more manageable.