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Rationale: Routine collection of outcome measures is advocated to improve quality of care. However, there has been scant investigation of how measurement tools are used in clinical practice and what impact they may have. This paper compares two neuro-rehabilitation teams, one which routinely used standardized measurement tools and the other which did not. We explore differences in communication and clinical decision making within multidisciplinary team (MDT) meetings to illuminate the influence measurement tools could have on clinical practice., Method: Non-participant observation of MDT meetings in two neurological rehabilitation units in England. Semi-structured interviews were also carried out with at least one member of each profession in each team. Grounded theory techniques were used to analyse the data., Results: Differences in team members' communication within MDT meetings underscored differences in the process of clinical decision making within the teams. Using measurement tools provided a shared understanding to facilitate communication by focusing discussion on the patient's abilities rather than individual professionals' contributions. This led to differences in the way team members identified the nature and cause of patients' problems, monitored their progress and planned for discharge. They provided a 'neutral ground' to reach a shared perspective between professionals, thereby avoiding conflict. Externally, use of the tools enabled objective discussion with patients and their families about their progress and was a vehicle to facilitate giving bad news., Conclusion: Using standardized measurement tools can promote a patient-focused approach to care, thus facilitating treatment planning and clinical decision making., (© 2010 Blackwell Publishing Ltd.)

Objective: To explore the experiences of young women adjusting to living with developmental dysplasia of the hip (DDH) and deciding on treatment choices., Methods: Exploratory study of a set of online postings from one message board aimed at women with DDH. Postings of five, purposively selected users were explored from first posting to the time of their peri-acetabular osteotomy surgery. Data analysis was performed through the approach of interpretive phenomenological analysis., Results: Two major concepts were prominent across participants' accounts; first, 'challenging the life course and identity as a young woman' and second, 'saving my joints'. Central was the women's description of how the diagnosis of DDH challenged the way they viewed themselves as young women. Once the women began to understand the long-term implications of having DDH they all began a quest to save their 'native joint', delaying the need for an artificial joint for as long as possible., Conclusion: The findings demonstrate the personal nature and diversity of the journeys the women followed. DDH potentially provides a critical case for exploration of the process of adjustment, as its treatment pathway and rehabilitation are lengthy and both physically and emotionally demanding.

This paper explores how multidisciplinary teams (MDTs) balance encoded knowledge, in the form of standardised outcome measurement, with tacit knowledge, in the form of intuitive judgement, clinical experience and expertise, in the process of clinical decision making. The paper is based on findings from a qualitative case study of a multidisciplinary in-patient neurorehabilitation team in one UK NHS trust who routinely collected standardised outcome measures. Data were collected using non-participant observation of 16 MDT meetings and semi-structured interviews with 11 practitioners representing different professional groups. Our analysis suggests that clinicians drew on tacit knowledge to supplement, adjust or dismiss 'the scores' in making judgements about a patients' likely progress in rehabilitation, their change (or lack of) during therapy and their need for support on discharge. In many cases, the scores accorded with clinicians' tacit knowledge of the patient, and were used to reinforce this opinion, rather than determine it. In other cases, the scores, in particular the Barthel Index, provided a partial picture of the patient and in these circumstances, clinicians employed tacit knowledge to fill in the gaps. In some cases, the scores and tacit knowledge diverged and clinicians preferred to rely on their clinical experience and intuition and adjusted or downplayed the accuracy of the scores. We conclude that there are limits to the advantages of quantifying and standardising assessments of health within routine clinical practice and that standardised outcome measures can support, rather than determine clinical judgement. Tacit knowledge is essential to produce and interpret this form of encoded knowledge and to balance its significance against other information about the patient in making decisions about patient care.

This paper applies a theory-driven approach to explore why the use of patient-reported outcome (PRO) measures in clinical practice, in particular, health-related quality of life (HRQoL) instruments, has little or no apparent influence on clinical decision making. A theory-driven approach involves combining knowledge of whether and how an intervention works. It is argued that such an approach is currently lacking within the literature evaluating the effectiveness of feeding back HRQoL information to clinicians. The paper identifies a number of mechanisms that might give rise to the expected outcomes that are currently implicit within the design of the intervention and hypotheses specified within the trials evaluating the use of HRQoL measures in clinical practice. It then examines how far current clinical practice matches these mechanisms and in doing so, a number of possible explanations for the lack of impact of HRQoL on clinical decision making are reviewed. The influence of HRQoL information on clinical decision making depends on a large number of factors related to the design of the intervention, patients' and clinicians' desire to discuss HRQoL issues within the consultation and the legitimacy that clinicians give to HRQoL instruments. To date, knowledge of how the feedback of HRQoL information to clinicians might improve doctor-patient communication or clinical decision making has yet to sufficiently inform an assessment of whether these aspects of patient care are improved. The paper concludes by specifying how the feedback of HRQoL information to clinicians might be modified to maximise its impact on clinical decision making.

Economic evaluation, linking the costs and consequences of an intervention to indicate the potential benefits of alternative interventions, is becoming established as one of the core tools for decision making in health care. As knowledge of the safety and effectiveness of complementary and alternative medicine (CAM) interventions increases, economic evaluation within CAM has a heightened significance.To explore whether the present framework for economic evaluation fits CAM and what modifications if any are needed for its application.Systematic review.A comprehensive search of four databases was undertaken (NHS Economic Evaluation Database, AMED, MEDLINE,™ CINAHL). Studies were included if they took the form of a comparative analysis of costs and consequences of a CAM treatment and were written in English. Each study was reviewed using a set of methodological questions to judge their quality as economic evaluations.A total of 19 studies were identified, of which 9 were cost-effectiveness studies, 7 cost-consequence studies, 2 cost-minimization studies, and 1 cost-benefit analysis. Seventeen (17) of the studies involved CAM treatments being used alongside mainstream or conventional treatments. The majority of the treatments aimed to alleviate pain, including chronic pain, back pain, neck pain, and migraine. Only a small minority of studiesaddressed wider outcomes of particular relevance to CAM disciplines. Nine (9) adopted a service provider perspectiveonly, 7 included wider sickness absence costs and 3 patient costs. Only 1 study included costs to relatives.The quality of the cost and benefit dimensions of the studies was mixed.A CAM sensitive approach to economic evaluation is required. This needs to include a focus on outcomes that explore the range of effects of CAM treatment, an exploration of the client's perspective and not just that of the service provider and study designs that facilitate the individualized practitioner approach so central to CAM treatment. [ABSTRACT FROM AUTHOR]

Opinion. Asserts that a culture of ongoing evaluation needs to be fostered and embedded within professional medical practice. Purchasing outcome in health care; Outcomes data at aggregate, population, and individual patient levels; The view that clinical medical research should provide practitioners with information on how to measure outcomes; How the debate concerning monitoring and outcomes has been confused.