Assessing the Implementation and Effectiveness of the Electronic Patient-Reported Outcome Tool for Older Adults With Complex Care Needs: Mixed Methods Study

Abstract

Background Goal-oriented care is being adopted to deliver person-centered primary care to older adults with multimorbidity and complex care needs. Although this model holds promise, its implementation remains a challenge. Digital health solutions may enable processes to improve adoption; however, they require evaluation to determine feasibility and impact. Objective This study aims to evaluate the implementation and effectiveness of the electronic Patient-Reported Outcome (ePRO) mobile app and portal system, designed to enable goal-oriented care delivery in interprofessional primary care practices. The research questions driving this study are as follows: Does ePRO improve quality of life and self-management in older adults with complex needs? What mechanisms are likely driving observed outcomes? Methods A multimethod, pragmatic randomized controlled trial using a stepped-wedge design and ethnographic case studies was conducted over a 15-month period in 6 comprehensive primary care practices across Ontario with a target enrollment of 176 patients. The 6 practices were randomized into either early (3-month control period; 12-month intervention) or late (6-month control period; 9-month intervention) groups. The primary outcome measure of interest was the Assessment of Quality of Life-4D (AQoL-4D). Data were collected at baseline and at 3 monthly intervals for the duration of the trial. Ethnographic data included observations and interviews with patients and providers at the midpoint and end of the intervention. Outcome data were analyzed using linear models conducted at the individual level, accounting for cluster effects at the practice level, and ethnographic data were analyzed using qualitative description and framework analysis methods. Results Recruitment challenges resulted in fewer sites and participants than expected; of the 176 target, only 142 (80.6%) patients were identified as eligible to participate because of lower-than-expected provider participation and fewer-than-expected patients willing to participate or perceived as ready to engage in goal-setting. Of the 142 patients approached, 45 (32%) participated. Patients set a variety of goals related to self-management, mental health, social health, and overall well-being. Owing to underpowering, the impact of ePRO on quality of life could not be definitively assessed; however, the intervention group, ePRO plus usual care (mean 15.28, SD 18.60) demonstrated a nonsignificant decrease in quality of life (t24=−1.20; P=.24) when compared with usual care only (mean 21.76, SD 2.17). The ethnographic data reveal a complex implementation process in which the meaningfulness (or coherence) of the technology to individuals’ lives and work acted as a key driver of adoption and tool appraisal. Conclusions This trial experienced many unexpected and significant implementation challenges related to recruitment and engagement. Future studies could be improved through better alignment of the research methods and intervention to the complex and diverse clinical settings, dynamic goal-oriented care process, and readiness of provider and patient participants. Trial Registration ClinicalTrials.gov NCT02917954; https://clinicaltrials.gov/ct2/show/NCT02917954

An Electronic Patient-Reported Outcomes Tool for Older Adults With Complex Chronic Conditions: Cost-Utility Analysis

“…The total cost of the ePRO tool was CAD $79,467 (~US $63,581; CAD $1733 [~US $1386] per person); of these, the technology component accounted for 90.89% (CAD $72,234 [~US $57,794]) of the total costs. The trial reported that ePRO combined with usual multidisciplinary care did not significantly impact patient HRQoL ( P =.24) or patient activation ( P =.17) [ 10 ]. Our base case analysis showed that, compared with the standard care, the addition of the ePRO intervention was associated with higher costs (CAD $7133 [US $5707] vs. CAD $5423 [US $4338] per patient) and slightly fewer QALYs (0.42 vs. 0.45) than usual care ( Table 2 ).…”

“…Consistent with the trial, the study population for this cost-utility study was community-dwelling individuals aged 60 years or older with complex chronic conditions, defined as diagnosed with 2 or more chronic conditions and 10 or more visits to their primary health care provider within the past year. This number of visits has been identified as an indicator of complexity [ 10 ]. Chronic conditions were identified through the FHTs electronic medical records.…”

“…Additional eligibility criteria included the perceived willingness to engage in goal-oriented care conversations, ability to use a smartphone or tablet, capable of providing consent to participate, and willing to complete surveys until completion of the trial. Detailed information on the trial can be found elsewhere [ 10 ].…”

“…The electronic patient-reported outcome tool (henceforth, called the ePRO tool) is one of such digital tools, which can facilitate collaborative care based on individualized goals created by older adults and providers, also known as goal-oriented care. The tool is delivered through the internet and mobile devices, and can be useful for complex care given their ability to improve access, continuity and efficiency of care, patient self-management, and communication [ 10 ].…”

“…A randomized trial had shown that ePRO plus usual care did not significantly improve the HRQoL in older adults with complex needs, partly due to recruitment challenges [ 10 ]. However, ethnographic data collected as part of the trial highlighted the importance of the coherence or meaningfulness of the intervention to the end users (ie, patients and providers) and uncovered the challenge to align coherence across diverse groups.…”