Our health services research study provides an initial understanding of the patient characteristics and MSK clinical care delivered in a Swiss university-based specialized outpatient hospital setting. We found that only 49% of the initial visits in 2019 had a patient-reported clinical outcome measure (PROM) that was extractable from routine clinical practice documentation retrievable from the hospital KISIM system. Our study found not only high numbers of missing data of PROMs, but also of sociodemographic information (e.g. 59% for civil status, 19% for profession, and 10% for insurance status).
The demographics and presenting main diagnoses for our study population were similar to other studies. The slightly higher percentage of women (52%) seeking chiropractic care has been described previously, whereas our patient population with the most common age group of 40–49 years (21.4%), followed by 50–59 years (20.9%), seems to be older compared to other chiropractic settings.18 The most common main diagnosis of low back pain, followed by neck pain, is consistent internationally18 and in other chiropractic teaching clinics.19–21 Patients averaged 7 chiropractic visits during their episode of care, with 83% having 11 visits or less. While 95% of chiropractic teaching institutions report the routine use of PROMs for low back pain patients,22 evidence about the current use of PROMs among chiropractors in routine clinical practices is limited.12 One study reported that almost 30% of a chiropractor population in Australia don't routinely assess patient-reported outcomes in clinical practice for low back pain patients.23 Other primary care settings have reported that 46%24 and 60%25 of physiotherapists use PROMs.
As in many healthcare settings, most of our data were stored in text form in reports and clinical documentation notes. In most healthcare settings, these electronic data sources are typically unstructured, heterogeneous, and incomplete.26 Other barriers for the routine use of PROMs are the additional work load associated with data collection and lack of clear guidelines on the data collection process (e.g. frequency, timing, and location of administration).11 The high missingness of sociodemographic information in our study, for example civil and insurance status, is likely due to patients often not providing complete information on nonmandatory disclosures on the personal data sheet required for the initial visit and/or the data not being transcribed into the electronic health record system by administrative staff.26
PROMs are important standardized tools to measure the effectiveness of patient-centred care,10 and evidence of their value in improving individual care9 and healthcare quality27,28 is increasing. Internationally, there is growing interest in the role of PROMs in facilitating quality improvement initiatives and focusing patient-centred and patient-relevant healthcare outcomes.8 To achieve best care, reducing inequities in provided healthcare is crucial.29 The linkage of patient-level outcomes with sociodemographic data is key for health equity monitoring to provide equitable access to high quality care.30 One of the three recommendations of the World Health Organization's Commission on the Social Determinants of Health in 2008 was to "measure and understand the problem and assess the results of action", stating hereby the need for routine data collection and monitoring systems.31
Strengths and limitations
A strength of our study was the inclusion of a relatively large unselected MSK patient population presenting to the Balgrist chiropractic polyclinic during 2019, so that it captures the heterogeneous sample of patients seeking MSK healthcare in a Swiss university hospital chiropractic medicine outpatient clinic. Our focus was descriptive in nature for the purpose of quality assurance and future healthcare quality improvement. Collection and analysis of real-world data facilitates integration of research findings into routine clinical practice.
The external validity of our study is limited by it being a single-centre study, and our findings may not be generalized to other outpatient settings. As data collection and data entry in retrospective cohort studies are not planned in advance, our data were limited by the information available and extractable from the electronic health record system. Missing information limited our ability to fully describe all characteristics of our study population and thus our findings.
Implications
Our study provides deeper insights into routinely collected clinical data about healthcare services and patient-reported outcomes at a university hospital chiropractic medicine outpatient clinic in 2019. By assessing the current data structure, quality and accessibility, we could identify data collection quality and performance gaps. The following overall aims and targets were established for our future health quality improvement initiative at the Balgrist chiropractic medicine clinic: 1) To improve the quality and structure of routine clinical documentation practices, 2) To better integrate routine electronic patient-reported outcome collection into routine clinical practice, and 3) To implement data quality evaluation and monitoring processes for quality assurance and chiropractic healthcare quality improvement.