Using Patient Evidence to Guide Clinical Care: Consulting the Other Expert in the Room

Abstract

The evidence-based practice movement in health care has gained both momentum and scrutiny since its inception. Previous IJATT editorials have highlighted the dynamic interplay among evidence sources including the clinician's internal evidence, best available external evidence, and patient evidence. 1,2 In general, health care professions have applauded the integration of these three sources for making clinical decisions, as it incorporates science/knowledge (external evidence), expertise/experience (internal evidence), and the values/preferences/experiences of the individual patient (patient evidence). 1,2 However, it seems that athletic training has focused predominantly on the utilization of the best available external evidence as the largest contributor to evidence-based practice (EBP); thus, our EBP education has primarily focused on the development of PICO questions (Patient or Population of interest, Intervention, Control or Comparison, Outcome of interest), searching and critically appraising external evidence. In our quest to become evidence-based practitioners, we have not given enough appreciation to the third source-patient evidence 2 (e.g., the patient's values, preferences, experiences, etc.). The integration of the patient in to decision-making in traditional athletic training settings is obscured by a lack of (a) clear clinical standards for achieving patient engagement and (b) the documentation and quantification of the patient's perspective. These challenges, combined with the nuances of patient individuality, have made a complex topic much more challenging.One critical component to patient-centered care is the use of patient-reported outcome measures (PROs). PROs (also known as patient-rated outcomes) are any report of a patient's health condition that comes directly from the patient. 3 PROs can come in many forms, including standardized questionnaires that may be general evaluations of health-related quality of life or which are diseasespecific (osteoarthritis, chronic ankle instability), region-specific (ankle, shoulder, low back), or domain-specific (pain, fear of movement, self-efficacy). Patient-generated problem-specific PROs, which allow the patients to specify the activities or problems of greatest concern and evaluate their progress on these items, also exist. The different types of PROs and the questions contained within the instruments drive patient-centered care by primarily assessing activity limitations and participation restrictions. These domains of the International Classification of Functioning (ICF) model 4 are often challenging to assess. However, PROs are the outcome of choice to ensure clinicians capture all three domains of patient-specific function when developing goals and treatment plans. In further alignment with the ICF model, PROs also have the potential to offer insight regarding environmental and personal contextual factors that can be huge barriers or facilitators to patient care and must be taken in consideration to achieve true patientcentered care.The addition...

Muddying the Water?: The Role of Verbiage in Patient-Reported Outcome Measures

“…The integration of PROMs into patient care supports communication between clinicians and patients, engages patients as partners in their care, and allows clinicians to obtain the patient's perspective on aspects of the ICF Model. 8 The use of these data can directly improve care by leading to more comprehensive evaluations (i.e., combining internal evidence, research evidence, and patient evidence) and the monitoring of patient progress to determine if improvement has occurred.…”

“…Patients have unique and different experiences, regardless of diagnosis, and PROMs allow health care providers to better understand how a particular injury or condition is impacting the patient from a wholeperson perspective. 8 Through the utilization of these instruments, the clinician is able to incorporate patient evidence into the decision-making process, and ultimately provide patient-centered care. 8…”

The Influence of Education and Environment on Patient-Reported Outcome Use in Athletic Training Clinical Practice

“…9,11 More prominent barriers to the use of PROMs by ATs include the following reported perceptions: a lack of relevance to the AT's patient, negative time consumption for the clinician and/or patient, sense that information gained is not worth the effort, feeling that instruments are only useful for research, and sense that instruments do not improve clinical practice or treatment planning. [9][10][11] The combination of these perceptions of PROMs as a low-value undertaking and the lack of clear clinical standards for achieving patient engagement in a manner which documents the patient's perspective 5…”

“…[2][3][4] The inclusion of PROMs in clinical practice is a critical component of EBP, as they can be a mechanism with which to incorporate the patient's perspective when developing and executing the treatment plan. 3,5 In addition, PROMs are also necessary to improve the documentation of clinical outcomes and to demonstrate the effectiveness of treatments or interventions in athletic training clinical practice. [6][7][8] Previous research [9][10][11] has demonstrated that the actual clinical implementation of PROMs into athletic training practice has been limited, with only 15% to 26% of athletic trainers (ATs) using PROMs in clinical practice There are many barriers to the use of PROMs in practice, including patient completion time, patient difficulty, patient confusion, time to complete and analyze PROMs, and lack of support.…”

Vestibular Rehabilitation Therapy for Management of Concussion: A Critically Appraised Topic

“…[7][8][9] It is recommended that athletic trainers actively identify concussion patients who are experiencing persistent vestibular symptoms through the use of subjective and objective assessments of dizziness and balance, and then to be prepared to refer concussed athletes with vestibular symptoms for appropriate care and treatment. Educating the patient on the importance of VRT is necessary to enhance compliance (agreeing to participate in a treatment protocol), adherence (sticking to that treatment protocol), and fidelity (participating in a treatment protocol faithfully) to the rehabilitation program, [22][23][24][25][26] resulting in better treatment outcomes. 27 Ultimately, future research may indicate a need for AT education to eventually include training in VRT.…”